Kindermann Dana R, McCarthy Melissa L, Ding Ru, Frohna William J, Hansen Jonathan, Maloy Kevin, Milzman David P, Pines Jesse M
Department of Emergency Medicine, George Washington University Hospital, Washington, DC.
Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC.
J Emerg Med. 2014 Jun;46(6):791-9. doi: 10.1016/j.jemermed.2013.12.002. Epub 2014 Mar 11.
There is growing pressure to measure and reduce unnecessary imaging in the emergency department.
We study provider and hospital variation in utilization and diagnostic yield for advanced radiography in diagnosis of pulmonary embolism (PE) and to assess patient- and provider-level factors associated with diagnostic yield.
Retrospective chart review of all adult patients presenting to four hospitals from January 2006 through December 2009 who had a computed tomography or ventilation/perfusion scan to evaluate for PE. Demographic data on the providers ordering the scans were collected. Diagnostic yield (positive scans/total scans ordered) was calculated at the hospital and provider level. The study was not designed to assess appropriateness of imaging.
There was significant variation in utilization and diagnostic yield at the hospital level (chi-squared, p < 0.05). Diagnostic yield ranged from 4.2% to 8.2%; after adjusting for patient- and provider-level factors; the two hospitals with an emergency medicine residency training program had higher diagnostic yields (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.6-2.5 and OR 1.9, 95% CI 1.5-2.4). There was no significant variation in diagnostic yield among the 90 providers after adjusting for patient, hospital, and provider characteristics. Providers with < 10 years of experience had lower odds of diagnosing a PE than more experienced graduates (OR 0.8, 95% CI 0.6-0.9).
Although we found significant variation in utilization of advanced radiography for PE and diagnostic yield at the hospital level, there was no significant variation at the provider level after adjusting for patient-, hospital-, and provider-level factors.
在急诊科测量并减少不必要的影像学检查的压力日益增大。
我们研究了在诊断肺栓塞（PE）时，医疗服务提供者和医院在先进影像学检查的使用情况及诊断率方面的差异，并评估与诊断率相关的患者和医疗服务提供者层面的因素。
对2006年1月至2009年12月期间到四家医院就诊的所有成年患者进行回顾性病历审查，这些患者接受了计算机断层扫描或通气/灌注扫描以评估是否患有PE。收集了开具扫描检查的医疗服务提供者的人口统计学数据。在医院和医疗服务提供者层面计算诊断率（阳性扫描数/总扫描数）。该研究并非旨在评估影像学检查的适宜性。
医院层面在使用情况和诊断率方面存在显著差异（卡方检验，p<0.05）。诊断率范围为4.2%至8.2%；在对患者和医疗服务提供者层面的因素进行调整后，两家设有急诊医学住院医师培训项目的医院诊断率更高（优势比[OR]为2.0，95%置信区间[CI]为1.6 - 2.5；OR为1.9，95%CI为1.5 - 2.4）。在对患者、医院和医疗服务提供者特征进行调整后，90名医疗服务提供者之间的诊断率没有显著差异。经验少于10年的医疗服务提供者诊断出PE的几率低于经验更丰富的毕业生（OR为0.8，95%CI为0.6 - 0.9）。
尽管我们发现医院层面在PE先进影像学检查的使用情况和诊断率方面存在显著差异，但在对患者、医院和医疗服务提供者层面的因素进行调整后，医疗服务提供者层面没有显著差异。
